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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Health and Safety at Work Policy

1. Purpose

The purpose of this policy is to establish a comprehensive framework for ensuring the health, safety, and welfare of all staff, people we support, visitors, and contractors within {{org_field_name}}.

This policy addresses the Health and Safety at Work etc. Act 1974 and associated health and safety regulations, together with the Care Quality Commission (CQC) Fundamental Standards in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended. Relevant regulations include Regulation 9 (Person-centred care), Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding service users from abuse and improper treatment), Regulation 15 (Premises and equipment), Regulation 17 (Good governance), Regulation 18 (Staffing) and Regulation 20 (Duty of candour). The policy records the arrangements used to assess, prevent and manage risk; it does not certify legal compliance.

Through the implementation of this policy, {{org_field_name}} will promote a positive health and safety culture, monitor applicable legal and regulatory requirements and take proportionate steps to maintain a safe working and living environment.

2. Scope

This policy applies to:

• All employees (including full-time, part-time, temporary, and agency staff).
• Volunteers, contractors, and external service providers working at {{org_field_name}}.
• People we support (residents) and their families and visitors.
• External regulators and inspectors, including the CQC and Health and Safety Executive (HSE).

Everyone working at or visiting our care home has a shared responsibility for ensuring health and safety standards are upheld.

3. Legal and Regulatory Framework

This policy has been reviewed against the following key legislation, regulations and statutory requirements, as amended and where applicable:

• Health and Safety at Work etc. Act 1974 – establishes the general duties of employers to ensure, so far as is reasonably practicable, the health, safety and welfare of employees and to protect people who may be affected by the undertaking, including people we support, visitors, contractors and members of the public.
• Management of Health and Safety at Work Regulations 1999 – requires suitable and sufficient assessment of risks to employees and others arising from the undertaking, appropriate preventive and protective measures, effective arrangements for planning, organisation, control, monitoring and review, and access to competent health and safety assistance.
• Workplace (Health, Safety and Welfare) Regulations 1992 – sets requirements for the health, safety and welfare of employees in relation to matters including maintenance, ventilation, temperature, lighting, cleanliness, room dimensions, traffic routes, sanitary facilities and welfare arrangements.
• Manual Handling Operations Regulations 1992 – requires hazardous manual handling operations to be avoided so far as is reasonably practicable and, where they cannot be avoided, to be suitably and sufficiently assessed and the risk of injury reduced so far as is reasonably practicable. These requirements apply to the moving and handling of both people and inanimate loads.
• Provision and Use of Work Equipment Regulations 1998 (PUWER) – requires work equipment to be suitable for its intended use, maintained in an efficient state and good repair, inspected where necessary and used only by people who have received appropriate information, instruction and training.
• Lifting Operations and Lifting Equipment Regulations 1998 (LOLER) – applies, where relevant, to lifting equipment used at work, including hoists and associated lifting accessories used to move people. Lifting operations must be properly planned by a competent person, appropriately supervised and carried out safely, and lifting equipment must undergo the required thorough examinations by a competent person.
• Control of Substances Hazardous to Health Regulations 2002 (COSHH) – requires risks arising from exposure to hazardous substances, including biological agents and Legionella bacteria where applicable, to be assessed and adequately controlled. Suitable arrangements must be maintained for the safe storage, handling, use and disposal of hazardous substances.
• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) – requires specified work-related deaths, injuries, occupational diseases and dangerous occurrences to be reported to the relevant enforcing authority within the applicable statutory timescales.
• Regulatory Reform (Fire Safety) Order 2005, as amended, including relevant amendments made by the Building Safety Act 2022 – places legal duties on the Responsible Person to undertake and keep under review a suitable and sufficient fire risk assessment, implement appropriate fire precautions, maintain fire-safety arrangements and equipment, provide information and training, plan for emergencies and maintain the required records.
• Where any premises operated by {{org_field_name}} contain two or more sets of domestic premises, the Responsible Person will determine whether the Fire Safety (England) Regulations 2022 apply and will comply with any additional duties that apply to those premises.
• Where premises fall within the defined scope of the Fire Safety (Residential Evacuation Plans) (England) Regulations 2025, which came into force on 6 April 2026, the Responsible Person will comply with the applicable requirements relating to relevant residents, person-centred fire risk assessments, mitigating measures, emergency evacuation statements, information sharing and building emergency evacuation planning.
• Health and Social Care Act 2008 and the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as amended – establishes the regulatory framework and CQC Fundamental Standards applicable to registered care providers. This includes requirements relating to safe care and treatment, safeguarding, premises and equipment, good governance, staffing and the statutory Duty of Candour.
• Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance – establishes the statutory infection prevention and control requirements that registered providers must take into account in demonstrating compliance with the relevant regulations.
• Health and Care Act 2022 amendments to the Health and Social Care Act 2008 and the Oliver McGowan Code of Practice on statutory learning disability and autism training – require CQC-registered providers to ensure that each person working for the purposes of the regulated activities receives learning disability and autism training appropriate to their role. The statutory Code of Practice sets the required standards for the content, level, delivery, involvement of people with lived experience, monitoring and evaluation of that training.

In complying with these requirements, {{org_field_name}} will have regard to applicable statutory guidance, Approved Codes of Practice and regulatory guidance issued by the Health and Safety Executive, Department of Health and Social Care, UK Health Security Agency, Ministry of Housing, Communities and Local Government, Care Quality Commission and other relevant competent authorities.

4. Key Principles of Health and Safety Management

4.1 Risk Assessment and Hazard Management

At {{org_field_name}}, we proactively identify, assess, and mitigate risks through a structured risk assessment process. Risk assessments are conducted regularly and whenever there is a change in working practices or environment.

Risk assessments focus on:

• Identifying potential hazards, such as slips, trips, falls, fire hazards, and infection risks.
• Assessing the likelihood and severity of harm.
• Implementing preventative and control measures to eliminate or minimise risks.
• Reviewing and updating risk assessments at least annually or following an incident.

Staff are trained in recognising and reporting hazards to ensure continuous safety improvements.

4.2 Safe Working Environment

{{org_field_name}} will provide and maintain premises, equipment and working arrangements that are safe for staff, people we support, visitors and other people who may be affected by our activities.

• The premises will be kept clean, secure, suitable for their intended purpose and properly maintained.
• Floors, corridors, stairways, communal areas, access routes and emergency routes will be maintained so far as reasonably practicable to prevent slips, trips, falls, obstruction and other foreseeable hazards.
• Work equipment will be selected, installed, positioned, maintained and used in accordance with the Provision and Use of Work Equipment Regulations 1998 and other applicable safety requirements.
• Staff will only use work equipment for which they have received appropriate information, instruction, training and, where required, competency assessment.
• Equipment used in the delivery of care or treatment, including mobility aids, profiling beds, hoists, slings and other medical or care equipment, will be suitable for the person and task, properly maintained and subject to appropriate servicing, inspection and safety checks.
• Where LOLER applies to lifting equipment used to lift people, including relevant hoists and lifting accessories, the equipment will be thoroughly examined by a competent person at least every six months or at the intervals specified within a legally compliant written scheme of examination. Reports of thorough examination will be retained and any defect presenting an existing or imminent risk of serious personal injury will be acted upon immediately.
• Appropriate pre-use checks will be completed for equipment where required. Staff must not use equipment that they know or reasonably suspect to be unsafe, defective, damaged, overdue for a required examination or unsuitable for the intended person or task.
• Defective equipment will be removed from use or otherwise made safe until repair, replacement or other appropriate action has been completed.
• Emergency exits, evacuation routes and access required by emergency services will be clearly identified where necessary and kept available for safe use.

Regular environmental and health and safety inspections will be undertaken. Hazards and defects identified through inspections, staff reports, incidents, equipment checks or other monitoring will be assessed and remedial action will be taken according to the level of risk.

4.3 Infection Prevention and Control

We implement robust infection prevention and control measures to minimise the risk of infections.

• Staff are trained in infection control, including hand hygiene, PPE use, and waste disposal.
• Regular cleaning schedules are followed, ensuring high-touch surfaces are sanitised.
• Personal Protective Equipment (PPE) is provided, ensuring safe working conditions for infection prevention.
• Isolation procedures are in place for individuals with infectious illnesses.

These measures comply with CQC Regulation 12 (Safe care and treatment), the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance, and current national infection prevention and control guidance issued by the Department of Health and Social Care and the UK Health Security Agency

(or successor bodies).

4.4 Water Safety and Legionella Control

{{org_field_name}} will assess and control risks associated with its hot and cold-water systems, including the foreseeable risk of exposure to Legionella bacteria.

A suitable and sufficient assessment of the risk of exposure to Legionella will be undertaken by a competent person in accordance with the Control of Substances Hazardous to Health Regulations 2002 and applicable Health and Safety Executive requirements.

The assessment and associated control arrangements will take account of the design and operation of the water system and the increased susceptibility of people who may be at greater risk from Legionnaires’ disease because of age, illness, disability, reduced immunity or other relevant factors.

Where a foreseeable risk is identified, {{org_field_name}} will implement an appropriate written control scheme. This will include, where applicable:

• identification of the person or persons responsible for managing and implementing the control measures;
• appropriate monitoring and control of hot and cold-water temperatures or other approved methods of controlling Legionella risk;
• arrangements for flushing infrequently used outlets;
• appropriate inspection, cleaning, descaling, maintenance and disinfection of water systems and associated equipment;
• action to prevent or appropriately manage stagnation and other conditions that could support bacterial growth;
• appropriate microbiological sampling or other monitoring where indicated by the risk assessment or applicable guidance;
• measures to balance the control of Legionella with the prevention of scalding, particularly for people who may be unable to recognise or respond to excessively hot water; and
• maintenance of appropriate records of assessment, monitoring, inspection, maintenance, remedial actions and review.

The Legionella risk assessment and control scheme will be reviewed when there is reason to believe that the existing assessment is no longer valid, following significant changes to the water system or its use, following relevant incidents or concerns, or when changes in the needs or vulnerability of people we support materially alter the risk.

4.5 Manual Handling and Moving People Safely

{{org_field_name}} will manage moving and handling risks in accordance with the Manual Handling Operations Regulations 1992, the Management of Health and Safety at Work Regulations 1999 and applicable requirements relating to work and lifting equipment.

The following hierarchy will be applied:

• hazardous manual handling operations will be avoided so far as is reasonably practicable;
• where hazardous manual handling cannot reasonably be avoided, a suitable and sufficient assessment of the risk will be undertaken; and
• appropriate measures will be implemented to reduce the risk of injury so far as is reasonably practicable.

Moving and handling arrangements involving a person we support will be person-centred and will balance the health and safety of the person and staff with the person’s independence, dignity, privacy, comfort, choices and abilities.

Where a person requires assistance with movement or transfers, a suitable individual moving and handling assessment and care plan will be completed. The assessment will consider, as applicable:

• what the person can do independently;
• their ability to bear weight and participate in the manoeuvre;
• mobility, balance and risk of falls;
• pain, fatigue, tissue viability, disability, involuntary movements or other relevant clinical or physical factors;
• communication, cognition, behaviour and ability to understand or follow instructions;
• the environment in which the manoeuvre will take place;
• the number of trained staff required;
• the equipment, hoist, sling or other handling aid required; and
• foreseeable changes in the person’s condition or circumstances.

The assessment and moving and handling plan must clearly identify the safe method to be used. Staff must follow the person’s current assessment and care plan and must not improvise an unsafe manual lifting technique.

The number of staff required for a transfer will be determined by the individual risk assessment, the equipment being used, the person’s needs and the manufacturer’s instructions. The presence of two members of staff does not, by itself, make an otherwise unsafe manual lifting technique acceptable.

Mechanical aids and other suitable equipment will be provided where identified as necessary. Hoists, slings and other equipment will only be used by staff who have received appropriate training and have been assessed as competent for the task.

Moving and handling assessments will be reviewed periodically and whenever there is a relevant change in the person’s needs, abilities, equipment or environment, following a moving and handling incident or near miss, or where staff identify that the existing arrangements may no longer be safe or appropriate.

All moving and handling incidents, injuries, equipment problems and near misses must be reported promptly so that appropriate action can be taken and the relevant risk assessment and care plan reviewed.

4.6 Fire Safety and Emergency Preparedness

{{org_field_name}} will manage fire safety in accordance with the Regulatory Reform (Fire Safety) Order 2005, as amended, and any additional fire-safety legislation that applies to the particular premises.

The Responsible Person will ensure that a suitable and sufficient fire risk assessment is carried out by a person competent to undertake the assessment. The assessment will consider all relevant persons, including people we support who may require assistance because of mobility, sensory, cognitive, behavioural or other needs.

The Responsible Person will:

• record the fire risk assessment and its significant findings and maintain a record of the fire-safety arrangements for the premises;
• record the identity of any person appointed or engaged to undertake or review the fire risk assessment;
• keep the fire risk assessment under regular review and review it whenever there is reason to suspect that it is no longer valid or where there has been a significant change affecting fire safety;
• implement appropriate preventive and protective measures identified by the fire risk assessment;
• ensure that fire-detection and warning systems, emergency lighting, firefighting equipment, fire doors, escape routes and other fire-safety measures are appropriately inspected, tested and maintained;
• ensure that emergency exits and escape routes remain available and are not obstructed;
• ensure that an appropriate emergency and evacuation strategy is established for the premises;
• ensure that sufficient competent people are available to assist in implementing evacuation and other emergency procedures;
• provide employees with adequate fire-safety information, instruction and training appropriate to their responsibilities;
• undertake fire drills and other testing of emergency arrangements at appropriate intervals and use the outcomes to identify required improvements; and
• retain appropriate records of fire-risk assessment, maintenance, testing, training, drills, incidents and corrective actions.

Individual evacuation arrangements will be developed and documented for people we support who may require assistance to reach a place of safety. These arrangements will be based upon the person’s individual needs and the evacuation strategy established by the fire risk assessment. They will identify the assistance, equipment, staffing and other arrangements necessary to support safe evacuation and will be reviewed when the person’s needs or relevant circumstances change.

The term Personal Emergency Evacuation Plan may be used within {{org_field_name}} for these individual care-home evacuation arrangements. Such arrangements must be distinguished from the separate statutory Residential PEEPs regime that applies only to buildings falling within the scope of the Fire Safety (Residential Evacuation Plans) (England) Regulations 2025.

Where any premises contain two or more sets of domestic premises, the Responsible Person will determine whether the Fire Safety (England) Regulations 2022 impose additional requirements and will implement all requirements that apply.

Where premises fall within the scope of the Fire Safety (Residential Evacuation Plans) (England) Regulations 2025, {{org_field_name}} will comply with the applicable statutory requirements, including those concerning identification of relevant residents, offers of person-centred fire risk assessments, reasonable and proportionate mitigating measures, emergency evacuation statements, review, information sharing with the relevant Fire and Rescue Authority and building emergency evacuation planning.

4.7 Reporting Accidents, Incidents, and Near Misses

To ensure a transparent and learning-focused approach, all accidents, incidents, and near misses are reported, documented, and reviewed.

• Staff must report any accidents, injuries, or dangerous occurrences to management immediately.
• All accidents, incidents and near misses must be recorded and assessed. A RIDDOR report is required only where the event falls within a specified work-related category. Fatalities and specified injuries must be reported without delay and the report received within 10 days; over-seven-day worker incapacitation must be reported within 15 days. Required RIDDOR records, including over-three-day worker incapacitation records, must be retained.
• Investigations are conducted to determine root causes and prevent recurrence.
• Findings from incidents inform staff training and safety improvements.

By fostering an open culture of safety reporting, we ensure continuous learning and risk reduction.

4.8 Staff Training and Competency

All staff undergo comprehensive health and safety training, including:

• Fire safety and evacuation procedures.
• Infection control and PPE use.
• Manual handling and moving residents safely.
• First aid and emergency response training.
• Safe use of hazardous substances (COSHH regulations).

Training and refresher arrangements will be reviewed according to role, risk, changes in law or guidance, incidents, audit findings and identified competence needs.

4.9 Statutory Learning Disability and Autism Training

{{org_field_name}} will ensure that every person working for the purposes of its regulated activities receives learning disability and autism training that is appropriate to their role, in accordance with section 20(5ZA) of the Health and Social Care Act 2008 and the Oliver McGowan Code of Practice on statutory learning disability and autism training.

{{org_field_name}} will undertake regular assessment of staff roles, responsibilities and required capabilities to determine the appropriate level of learning disability and autism training for each member of staff.

The following requirements will apply:

• All staff will receive training covering the minimum learning disability and autism capabilities applicable to their role.
• Staff who require general awareness of people with a learning disability and autistic people and the support they may need will receive training meeting the applicable Tier 1 capabilities.
• Staff who provide care or support, interact substantially with people using the service, make decisions affecting the service, or otherwise require greater capability because of their role will receive training meeting the applicable Tier 2 capabilities and any additional capabilities required for their responsibilities.
• In accordance with the statutory Code of Practice, care-home staff who provide direct care or support will normally require Tier 2 capabilities. Staff whose duties do not involve contact with people using the service or decisions affecting them may require Tier 1 capabilities where supported by the role and skills assessment.
• Staff whose roles involve complex care, leadership or specialist learning disability or autism responsibilities will receive any additional Tier 2 or Tier 3 capabilities identified as necessary through assessment of their role.
• All staff will complete the required e-learning element covering the minimum Tier 1 capabilities and will also receive the minimum amount of live and interactive training required by the Code.
• The live and interactive element of training will be co-produced and co-delivered with people with a learning disability and autistic people. This is a required training standard and will not be treated as optional.
• Staff requiring general awareness will receive at least the minimum live and interactive training specified by the Code. Staff requiring the capabilities applicable to care and support roles will receive the required in-person training appropriate to that level.
• Learning disability and autism training will be repeated at least every three years. Training will be undertaken sooner where required because of a change in role or responsibilities, promotion, an identified learning or competency need, changes in practice or another relevant reason.
• {{org_field_name}} will maintain records sufficient to demonstrate each member of staff’s required level of training, training undertaken, completion dates, refresher due dates and any additional learning identified.
• {{org_field_name}} will assess whether learning from the training has been understood and embedded into practice and will take action where further support, supervision, competency assessment or training is required.

The Oliver McGowan Mandatory Training on Learning Disability and Autism is the Government’s preferred and recommended training package. Where {{org_field_name}} uses another training programme, the provider will ensure that it demonstrably meets all applicable standards contained in the statutory Oliver McGowan Code of Practice.

Compliance with this section will form part of {{org_field_name}}’s staff training, supervision, competency and governance arrangements and will be monitored in accordance with CQC requirements.

5. Monitoring and Compliance

{{org_field_name}} will maintain effective systems and processes to assess, monitor and improve health and safety and to identify, assess and mitigate risks to people we support, staff and others who may be affected by our activities.

To monitor implementation and identify improvement needs:

• quarterly health and safety audits will be conducted;
• risk assessments will be reviewed and updated at appropriate intervals and whenever there is reason to believe that an assessment is no longer valid, following significant change, or following an incident, near miss or other information indicating that controls may no longer be sufficient;
• statutory inspections, examinations, testing, maintenance and monitoring will be completed within the required timescales and appropriate records will be retained;
• health and safety incidents, accidents, near misses, hazards and concerns will be recorded, investigated and reviewed according to their nature and level of risk;
• required notifications and reports to the Health and Safety Executive, Care Quality Commission, Fire and Rescue Authority or other relevant statutory body will be made where the applicable legal reporting criteria are met;
• CQC inspections and assessments will be supported by accurate and accessible evidence demonstrating compliance;
• staff feedback, health and safety meetings, audits, incidents, complaints, safeguarding concerns and other relevant information will be used to identify risks, trends and opportunities for improvement; and
• actions identified through audits, assessments, incidents or other governance processes will be allocated, monitored and followed through to completion.

Where an incident meets the statutory definition and threshold of a notifiable safety incident under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, {{org_field_name}} will comply with the statutory Duty of Candour.

As soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred, the relevant person will be notified in accordance with the Regulation. The notification will:

• be given personally by an appropriate representative of {{org_field_name}};
• provide an account, which to the best of {{org_field_name}}’s knowledge is true, of all the facts known about the incident at the time of notification;
• explain what further enquiries into the incident are considered appropriate;
• include an apology; and
• be accompanied by reasonable support appropriate to the relevant person.

The notification will subsequently be followed by written notification containing the information provided, details of any further enquiries undertaken or to be undertaken and an apology.

{{org_field_name}} will maintain a secure written record of the Duty of Candour notification, communications, support provided, written follow-up and other actions taken.

Learning arising from accidents, incidents, near misses, safeguarding events, complaints, Duty of Candour events, audits and other health and safety information will be incorporated into the organisation’s governance arrangements. Actions and improvements will be monitored to ensure that identified risks are reduced and that learning results in sustained improvement in practice, in accordance with Regulation 17 (Good governance).

6. Policy Review

This policy is reviewed annually or earlier if regulatory changes, workplace incidents, or new best practices emerge.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.